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Phase 2a > Rheumatology > Flashcards

Rheumatology Flashcards

1
Q

Definition of osteoarthritis?

Why is not called “wear and tear” anymore?

A

Degenerative disease of joints resulintg in loss of articular cartilage

More complex - remodelling of bone and inflammation occurs

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2
Q

5 X-ray points of OA?

A 
Narrowed joint space
Osteophyte formation
Sub-chondral sclerosis
Sub-condral cysts
Abnormalities of bone contour
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3
Q

5 risk factors of osteoarthritis?
What cell will these risk factors affect?
What do they start producing instead?

A

Age, Biological sex, Obesity, Trauma, Sport

Chondrocyte activity

Produce type 1 collagen instead of type 2 collagen - will eventually undergo apoptosis

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4
Q 
PRESENTATION OF OA?
Hand nodes are called?
Limited ...?
Touch and it is...?
Would hear...?
Joint may be swollen because of...? (3)
A

Bouchard’s (PIP)
Heberden’s (DIP)

Limited range of movement

Tender

Crepitus

Bony enlargements, effusion, synovitis

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5
Q

What joints are commonly affect by OA:
In the hand?
3 others?

A

DIP (unique), PIP, 1st CMC

Knees, Hips, Lower lumbar spine

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6
Q

OA vs RA presentation:
Time?
Exercise? - why?
Symmetry?

A

OA: longer than 1 hour
RA: less than 30 minutes

OA: made worse with exercise (rubbing)
RA: made better with exercise (debris cleared)

OA: often non-symmetrical
RA: often symmetrical

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7
Q

What causes locking in OA?

What is name of the procedure for fixing it?

A

A loose body - bone or cartilage fragment

Removed with arthroscopy

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8
Q

3 categories of management in OA?

Examples in each…

A

Non-medical:
Patient education, activity & exercise, weight loss, physiotherapy, footwear, walking aids

Pharmacological:
Topical - NSAIDs, Capsaicin, Oral - Paracetamol, NSAIDs, Opioids,

Surgical:
Arthroscopy (loose bodies)
Osteotomy (change bone length)
Arthroplasty (replacements)

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9
Q

What is the classical population for RA?

What is the associated genetic link?

A

Middle-aged women (2 to 3 more times likely in women)

Association with HLA-DR4 (especially) and HLA-DR1

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10
Q

Presentation of RA:
What joints are normally affected? - common (4) and less common (4)

What other geneal symptoms might present? (4)

A

PIP, wrists, MTP, MCP
ankles, knees, elbows

Fever, malaise, myalgias, weight loss

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11
Q

RA on XRAY? (3)

A

Bony erosions
Soft tissue swelling
Narrowing of the joint space

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12
Q 
Extra-articular manifestations in RA:
Skin - 2
Vascular - 1
Eyes - 2
Pulmonary - 2
Lymph nodes become...?
Cyst name?
A

Skin: Raynaud’s, Nodules

Vascular: vasculitis

Eyes: scleritis, episcleritis

Pulmonary: pleural effusion, pulmonary fibrosis

Lymph nodes may become palpable

Baker’s Cyst

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13
Q

2 antibodies tested for in RA?
- percentage and explanation for one of these?
2 common complications of RA?

A

Rheumatoid Factor - IgM autoantibody against Fc poriton of IgG, 80% of case

Anti-CCP (anti-cyclic citrullinated peptide)

Anaemia of chronic disease - hepciin production
Secondary amyloidosis

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14
Q

What is Felty Syndrome?

High risk of…?

A

Rheumatoid Arthritis combined with…
Splenomegaly
Granulocytopenia/anaemia/neutropenia

High risk of infections

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15
Q

2 categories of management in RA:
2 examples -

4 examples -
B-cell one (CD20)
T-cell one
Three TNF ones

A

Disease-modifying anti-rheumatic medications (DMARDs):
Methotrexate & folic acid
Sulfasalazine

Biologics:
Rituximab (B-cells)
Abatacept (T-cells), Adalimumab, Etanercept, Infliximab (chemokines - TNF)

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16
Q

What are the two medications for acute flare-ups of RA?

A

NSAIDs and glucocorticoids

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17
Q

Crystal arthritis on microscopy:
Gout = ?
Pseudogout = ?

A

Monosoidum urate (negatively birefringent needles) = gout

Calcium pyrophosphate (weakly positive rhomboids) = pseudogout

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18
Q

What is urate crystals made from? 4 examples of these

Key enzyme involved in the metabolism of purines?

Main example of a known diseease that increase production of uric acid?

A

PURINES
Caffeine, xanthine, adenine, guanine

Xanthine oxidase

Lesch-Nyhan syndrome

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19
Q

What is major symptom in gout?
Main joint - special name? Why?
Other joints?

Chronic gout leads to:
“onion like aggregates” called…
increased risk of…

A

Severe pain and inflamed joint

Big toe (podagra)
Ankle/foot, knee, elbow, wrist

Tophi (aggregates of urate crystals)
Increased risk of kidney stones and urate nephropathy

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20
Q

What are the dietary triggers of gout?
Two non-dietary triggers?
Classic medication trigger?

A

Shellfish, red meat
Fructose, alcohol

MI, sepsis

Diuretics

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21
Q

GOUT MANAGEMENT:
Patient education = ?
Anti-inflammatory drugs = (3) and order
Specific drug? When is it used?

A

Patient education - hydration, diet, stay active

1st NSAIDs,
2nd colchicine,
3rd steroids

Recurring/chronic gout: xanthine oxidase inhibitor (allopurinol)

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22
Q

What is the name of the crystals in pseudogout?
Which joints to these typically affect?
Normal age of affected?

A

Calcium pyrophosphate

Typically knees and wrists

Elderly - often alongside degenerative disease

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23
Q

Osteoporosis definition vs Osteomalacia definition?

A

Osteoporosis - low bone mass and microarchitectural deterioration

Osteomalacia - softening of bone due demineralisation

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24
Q

Who does osteoporosis affect the most?
Primary risk factors for osteoporosis?
Secondary risk factors - diseases (two categories)

A

Elderly women - 1 in 3
1 in 5 men

Age, Menopause (oestrogen), genetics, smoking, low BMI, immobility

Chronic disease - inflammation causes resorption
Endocrine disease - parathyroid, thyroid, cortisol, oestrogen

25
At what age do you have peak bone mass? Overall principle of osteoporosis pathophysiology? Two types?
Age 29 - possibly later in females? RESORPTION > FORMATION Post-menopausal (oestrogen effect) Senile (osteoblasts worn out)
26
What are the usual fractures that occur in osteoporosis? (3) | What is the name of the questionnaire used to predict risk?
Vertebral fractures - lumbar spine Hip and wrist fractures FRAX - predicts risk for those over 40
27
What is the scan used to assess osteoporosis? Produces a "..-score" 3 ranges and associated classification
``` DEXA scan (dual X-ray absorptiometry scan) T-score ``` Normal > -1 Osteopenia -1 to -2.5 Osteoporosis < 2.5
28
Management of osteoporosis: Lifestyle advice = ? Anti-resorptive drugs - work by? Examples? Anabolic - work by? Main example?
Education, stop smoking and alcohol, exercise, calcium and vitamin D diet Anti-resorptive (decrease osteoclast activity) • Bisphosphonates - 1st line, usually alendronate (disables osteoclasts) • Denosumab - monoclonal antibody to RANK-L • HRT - does increase other risks Anabolic (increase osteoblast activity) • Teriparatide (PTH analogue)
29
What is the genetic association with spondyloarthritis? What skeleton does it classically affect? 3 main examples 3 smaller examples
HLA-B27 Usually affect the AXIAL SKELETON * Ankylosing spondylitis * Reactive Arthritis (& Reiter's syndrome) * Psoriatic arthritis Enteropathic arthritis, Undifferentiated spondyloarthritis, Childhood arthritis
30
What area of the world is AS classically common in? Classic population? UK prevalence?
High in Scandinavia - young adult males | 0.5% prevalence in UK
31
What joints does AS affect? Leads to what presenting complaint? What are the two classic associations?
Sacroiliac joint and spine (fusion - bamboo spine) Lower back pain Uveitis & Aortitis
32
What is classic pathogen which causes Reactive arthritis? Other pathogen cateogry? What is the two associations? - saying Which joint?
Chlamydia trachomatis Or general GI infection arthritis, urethritis (circinate balanitis) and bilateral conjunctivitis - "can't see, can't pee, can't climb a tree" Monoarthritis of the knee
33
How many cases of psoriasis have psoriatic arthritis? Involves what joints? Specific joint causes what specific condition in fingers? What nail changes can occur?
10% of cases Involves axial and peripheral joints Affects DIP - leading to dactylitis (sausage fingers and toes) And psoriatic nail changes - pitting, onycholysis, hyperkeatosis
34
What are the two categories of septic arthritis causes? How does each spread? How many or which joint in each?
N gonorrhoeae - spreads haematogenous, affects multiple joints, causes multiple lesions NON-GONOCOCCAL ARTHRITIS: Often S aureus, affect single joint - often knee
35
How does septic arthritis present? | What is the major risk in septic arthritis?
Joint - inflamed, with reduced ROM Fever, increased WBC and elevated ESR RISK: Intra-articular pressure compresses blood vessels and leads to necrosis
36
``` Osteomyelitis bacteria: Two most common? Salmonella is linked to? Pasteurella is linked to? Pseudomonas is linked to? TB is called "... disease" ```
S aureus (most) & N gonorrhoeae Salmonella (sickle cell) Pseudomonas (diabetes or IV) Pasteurella (dog/cat bite/scratch) TB (Pott's disease)
37
Where does osteomyelitis normally affect in children and in adults? What is a major risk factor for osteomyelitis?
Childen - metaphysis of long bones (mostly affects) Adults - vertebrae Prosthetic joints
38
What are 3 types of osteomyelitis (spread)? Which population is affected by each?
Direct inoculation - those with recent trauma/surgery Contingous spread - older adults Haematogenous - children
39
Name the two main inherited connective tissue disorders. Name the four main autoimmune connective tissue disorders.
Marfan's Syndrome Ehler's Danlos Syndrome SYSTEMIC LUPUS ERYTHEMATOSUS (SLE) SYSTEMIC SCLEROSIS (including CREST) PRIMARY SJOGREN'S SYNDROME DERMATOMYOSITIS/POLYMYOSITIS
40
What would someone with Marfan's look like? What are the two major parts of the body that are affected by complications? It is a mutation in what gene? What type of genetic disorder?
Tall, slender with long fingers Lens dislocation in eyes Aortic dilation, aneurysm and rupture Mutation in FBN1 gene - Fibrillin 1 (autosomal dominant)
41
The Ehler's Danlos disorders cause a defect in what metabolism? Mutations in what genes?
Collagen metabolism COL5A or COL3A
42
What is classic population affected by SLE? Why this population specifically? What another common trigger? What type of hypersensitvity reaction?
Women of reproductive age Link with non-white populations Association with oestrogen Medications T3 hypersensitivty - immune complexes that cause inflammation
43
``` Presentation of SLE: General - 3 Mucosa - 2 Skin - 3 Neurological - 2 Pulmonary - 1 + 2 Cardiovascular - 1 + 3 Renal - 1 Haematological - 3 Joints - 1 ```
General - fever, malaise, weight loss Mucosa - mouth/nose ulcers Skin - UV sensitivity butterfly rash, photosensitive discoid rash, Raynaud's Neurological - headache, seizures Pulmonary - pleuritis, pleural effusion, fibrosis Cardiovascular - pericarditis, myocarditis, endocarditis (Libman-Sacks), HTN Renal - nephritis Haematological - anaemia, leukopenia, thrombocytopenia Joints - arthritis (two or more)
44
What is the biochemical test associated with SLE? Is it a good test? What are the two major complications of SLE?
ANTINUCLEAR ANTIBODY (ANA) - sensitive, but not specific (RA, CREST, Sjogren's) Complications Osteoporosis - low vitamin D (sun exposure) Secondary antiphospholipid syndrome - hypercoagulable state due to antibody targeting proteins bound to phospholipid
45
Systemic sclerosis: Possible pathophysiology? What does CREST stand for?
Unknown pathophysiology - possibly increased T-helper cells in skin CREST - less severe form Calcinosis - calcium deposition in skin Raynaud's - artery spasm in fingers Oesophageal dysmotility - swallowing difficulty Sclerodactyly - skin tightening over fingers Telangiectasias - small dilated blood vessels on skin surface
46
What are the two glands normally affected in Sjogren's syndrome? What happens to them? Other areas that can become affected? Is it ANA positive?
Lacrimal glands: dry eyes (keratoconjunctivitis), eye problems Salivary glands: xerostomia (cracks, fissures, taste/swallowing problems) Can also affect nose, throat, skin, vagina It is ANA-positive, specifically Anti-ssA and Anti-ssB
47
What is the difference between polymyositis and dermatomyositis?
Polymyositis - multiple muscles - often shoulders, hips, thighs Dermatomyositis - polymyositis with a skin rash (eyes, face, hands/fingers)
48
What are the 3 main risk factors for bone malignancy?
Radiation - XR or CT Paget's disease Familial retinoblastoma (osteosarcoma)
49
What are the 5 cancers which often spread to bone? Are these secondary tumours more or less common than primary tumours of bone? Are they normally osteolytic or osteoblastic? What is the exception to this?
Breast, prostate, kidney, thyroid, lung More common than primary tumours Usually osteolytic (punched-out) lesions Apart from prostatic carcinoma - which classically produces osteoblastic lesions
50
Name 4 out of the 5 benign tumours of bone?
``` Osteoma Osteoid osteoma Osteoblastoma Osteochondroma Chondroma ```
51
Name 3 malignant bone tumours | Where does each classically grow? (which bone and where in the bone?)
Osteosarcoma (osteoblasts) - (metaphysis, bones around knee) Ewing sarcoma (neuroectoderm) - (diaphysis of long bones) Chondrosarcoma (cartilage) - (medulla of pelvis or central skeleton)
52
What is the classical population that suffers from fibromyalgia? What actually is fibromyalgia? Known pathophysiology? Associations?
Muscle pain with no signs of inflammation Non-specific muscular disorder with unknown cause (link to pain pathway problems) 10x more common in females, middle age, low household income, divorce Associations: IBS, chronic headache, depression, chronic fatigue syndrome
53
How does fibromyalgia present? How long should it be present for? How can you diagnose this?
Muscle pain worse with stress, cold, weather activity Morning stiffness < 1 hour Sleep disturbance (other symptoms) Widespread symptoms of > 3 months Presence of pain at specific palpation sites, suitable history, and associations present
54
What is the difference between rickets and osteomalacia? What links them together as a definition? Pathophysiological princple?
Rickets - in children (softening, impaired growth, malformations) Osteomalacia - in adults (weakening, softening) "bone softening - faulty process of bone mineralisation" Impaired vitamin D, phosphate or calcium metabolism Therefore, reduced mineralization
55
What are the risk factors for developing osteomalacia/rickets? (4)
``` VIT D DEFICIANT: Malabsorption (coeliac or Crohn's), Reduced UV light, Medications - anticonvulsants, Liver and Kidney disease ```
56
How does someone with osteomalacia present? (5)
``` Diffuse bone and joint pain Proximal muscle weakness Bone fragility Increased risk of fractures Muscle spasms and numbness ```
57
How does a child with Ricket's present? (5)
``` Craniotabes (softening or thinning of the skull) Delayed closure of fontanelles Genu varum (varus, bow-legs) Protruding abdomen Prominent frontal bone ```
58
What is the proper name for "brittle bone disease" What is the most severe type? What happens to the eyes?
Osteogenesis imperfecta - type 1 collagen is affected Type I is mild, Type II is severe Association with blue sclerae
59
What occurs in Paget's disease of bone? (basic pathophysiology) Early on it is... Over time (3)
Excessive bone resorption followed by excessive bone grwoth after osteoclast burn out Early on it is asymptomatic Over time: Can impinge on nerves (pain) Overgrowth - leontiasis (caveman face), hearing loss, vision loss Risk of osteosarcoma

Phase 2a (9 decks)

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